American Public Health Association Annual Meeting Boston, MA. Nov 8, 2006

1. Lessons learned about environmental alcohol strategies from the 'A Matter of Degree' Program in College CommunitiesDonald W. Zeigler, Ph.D., Deputy Director American Public Health Association Annual Meeting Boston, MA. Nov 8, 2006 ATOD Session 5149.0. Whether on the Street or in the Classroom: Your Drinking Behaviors & Solution

2. A MATTER OF DEGREE: The national effort to reduce high risk drinking among college students A partnership of the American Medical Association and The Robert Wood Johnson Foundation

3. A Matter of Degree goals • Test efficacy of environmental model • Create sustainable campus-community partnerships to address entire student environment • Reduce high-risk drinking & 2nd-hand effects

4. 1996 Campuses invited to join. Criteria: • High student binge rates • Campus history of addressing alcohol issues • Willingness to discuss problems publicly - “stick necks out” • Willingness to collaborate with community partners • Active participation and support of chief executives (President, Mayor)

5. Overview of AMOD • 10 campus-community coalitions • 8-9 year grants [Colorado 5 years] • Average grant of $700,000 + school match • Evaluation: Harvard School of Public Health with its on-site evaluators • AMA – national program office

6. University/City Coalitions • U of Delaware - City of Newark • Florida State U - City of Tallahassee • Georgia Institute of Technology - City of Atlanta • U of Iowa - Iowa City • Lehigh U - City of Bethlehem • Louisiana State U - City of Baton Rouge • U of Nebraska - City of Lincoln • U of Vermont - City of Burlington • U of Wisconsin - City of Madison • U of Colorado – City of Boulder

7. AMOD targeted predictors of college high-risk drinking(Wechsler et al., 1994) • 1+ alcohol outlets within 1 mile of campus • 1st year undergraduates • Males • Athletes • Sports fans • Greeks, especially fraternity members

8. Underage alcohol market on campus: U of Iowa, Iowa City • 60% of students under age 21 • Underage spend $235,458/month on alcohol • Wholesale cost: $47,091 = 80% profit • $2.1 million/year est. income on UA drinking Jim Clayton, Director, Stepping Up Project U of Iowa, October 27, 2004

9. All about price. Drink fast! Iowa City • Price specials every night • Web advertising • Text messages on the cell phone about specials • E mail notices about bar specials

10. Rates of growth Iowa City1975 9 liquor licenses downtown 6 were bars1981 17 10 1998 33 20 2005 48 32

11. AMOD interim evaluation 1997-2001Harvard School of Public Health • Compared drinking and harm patterns from 10 AMOD schools to • 32 non-AMOD colleges from the national Harvard College Alcohol Study (CAS)

12. Evaluation • Divided 10 AMOD program colleges into 2 groups based on their level of program implementation (# and variety of policy changes) as of 2001: • high intervention • low intervention sites Weitzman ER, Nelson TF, Lee H, Wechsler H. (October, 2004). Reducing drinking and related harms in college: Evaluation of the “A Matter of Degree” program. American Journal of Preventive Medicine, Oct 2004

13. AMOD Findings (1997-2001):Adapted from Weitzman, Nelson, Lee & Wechsler,AJPrevMed, 2004 # Interventions High Low among all AMOD sites Availability 26 5 Legal sanctions 21 4 Physical context 8 2 Advertising & Promotion 7 4 Key influencers 16 8 Sociocultural context 79 23

14. 5 high intervention schools: • Significant changes noted in drinking & related harms over time when compared to the non-AMOD colleges. • Decreasing relative risk over time • Reduced driving after drinking, driving after 5+ drinks, riding with drunk driver

15. Reductions did not occur at • the 5 universities that implemented fewer of these changes • nor at the group of 32 comparison colleges

16. 5 high intervention sites:5-11% reductions in 6 consumption outcomes • “Binge” drink • “Binge” frequently • Taking up “binge” drinking in college • Drink frequently • Get drunk frequently • Usually drink at “binge” level

17. Drinkers at 5 High Implementation Schools:18% reductions in experience of 5 or more alcohol related harms • getting hurt or injured • medical treatment for overdose • unprotected, unplanned sex • miss or fall behind classes • getting in trouble with police • do something regretted

18. 5 high intervention schools: 10% fewer 2ndhand effects from other students’ heavy alcohol use, e.g. • property vandalized • interrupted sleep or study time • arguments, insults or assaults • unwanted sexual advance • baby sit a student

19. Examples of policies and programs found effective to-date: • mandatory training for responsible beverage service • required registration for purchasers of kegs • prohibit sales of alcohol without a license • keep alcohol-related items out of student bookstores • expand substance-free residence halls • promote alcohol-free activities.

20. AMOD comprehensive college/community environmental interventions, “if vigorously pursued,can reduce drinking problems specifically among college students.” • “It can alsoreduce secondhand effects of alcohol perpetrated on other college students by students who engage in excessive college drinking.” • “This careful and rigorous evaluation is the first to show positive benefits of interventions across entire college populations, not just select subgroups of students.” Hingson, R. (2004). Advances in Measurement and Intervention for Excessive Drinking. Am J Preventive Medicine. 27(3):261-263.

21. Plausible mechanisms: • Diminished alcohol availability • Increased enforcement • Heightened scrutiny – self regulation • Moderated peer influences – less tolerance for drunkenness, more concern about it • Time spent on other things, culture shift

22. Underlying dynamics supportive of change: • Long term voluntary commitment to coalition efforts & policy change • Willingness of institutions to see school as activist change agents • Shift from individual-only to include environment approaches

23. High 5 coalitions • More formal structures & processes • Higher member involvement in decisions • Assume environment is changeable & supportive • Clear, flexible, detailed strategic & action plans • Staff facilitates rather than directs • Responsible, trusted leadership • Consensus-driven

24. Likely causes for lower levels of intervention (differ per site) • Active alcohol industry opposition • Fear of angering students • Community made up of multiple autonomous groups and not working as a whole • Poor leadership • High adult drinking in state • Few state policy measures

25. Potential threats to campus/community coalition (LSU experience) • Changes in top administration may impact ongoing commitment • Untrained and unskilled leadership • Inadequate professional staff time & coalition resources • Lack of personal conviction & courage of partners and staff • Lack of ability to withstand public apathy, cynicism and criticism

26. Empowered universities to take lead in communities Alcohol - a medical & public health issue Underage & young adult drinking are medical problems Physicians should be involved in patient screening, brief intervention, referrals to treatment in policy development and advocacy AMA helped change how we talk about alcohol

27. AMA Study: “Effects of Alcohol on the Brains of Underage & College Students”: • Brain damage and neuro-cognitive deficits • Affects learning abilities and intellectual development of underage drinkers • Impaired intellectual development may continue to affect individuals into adulthood • Imperative for policy-makers and organized medicine to address the problem of underage drinking Zeigler, DW, Wang, CC, Yoast, RA, Dickinson, BD, McCaffree, MA, Robinowitz, CB, and Sterling, ML. (January. 2005). The neurocognitive effects of alcohol on adolescents and college students. Preventive Medicine. 40(1): 23-32.

28. Responding to Depression, Suicide, Substance Use, and Addiction on College CampusesD-345.995 • Full insurance parity for mental health and substance abuse treatment • Colleges: increase availability and ensure the quality and quantity of on-site mental health and substance abuse clinical services &/or improve access to appropriate community services. • End discrimination against students who disclose or seek treatment for depression, SUD, or mental health issues, including mandatory suspension/withdrawal from school for students who request or receive psychiatric or addiction medicine services. • Urges similar programs in medical schools. • Urges clinical staff of campus health services and counseling services to improve their skills in screening, brief intervention and referral for students’ problem drinking. • Partner to educate physicians & media on the linkages of substance use and addiction, mental disorders, and suicide among college students. (CSAPH Rep. 8, A-06)

29. Underage drinking is an adult issue “Just because we hold youth responsible doesn’t mean the rest of us aren’t responsible too” “The alcohol industry needs to be held accountable” Alcohol problems are community problems requiring community solutions AMA helped reframe the issues –

30. New AMA policy: Increasing Taxes on Alcoholic BeveragesD-30.995 • Supports increases in federal taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the prevention, treatment of dependent or at-risk drinkers, services for vulnerable populations • Urges state & local medical societies to support increases in state and local taxes on beer, wine, and liquor • Support state & local efforts to increase taxes on beer, wine, and liquor • Collaborate with national medical specialty societies, the APHA, the Center for Science in the Public Interest, MADD • Use ballot initiatives in the 24 states that allow such initiatives. (Res. 438, A-05)

31. New AMA policy: Take Action to End Alcohol Ads on College Sports TelecastsD-30.994 •  Goal: end alcohol advertising on sports broadcasts & particularly on college sports; special emphasis on athletic conferences now or soon negotiating contracts, • Appeal directly to the NCAA, all athletic conferences and member schools to end alcohol ads on their broadcasts; • Urge physicians, particularly those in or associated with college communities, express opposition directly to top administrators; • Urge state & local medical associations to contact colleges & press them to end alcohol ads on their broadcasts; • Urge state and local medical associations to get state legislatures to pass resolutions requesting colleges in their state to end alcohol ads on their broadcasts; & • Organize "sign-on" letter from medical societies to the NCAA President and Executive Committee urging an end to alcohol ads on NCAA broadcasts. (Res. 413, A-06)

32. Statement on Reducing the Global Impact of Alcohol on Health and Society submitted by the AMA adopted by the World Medical Association Santiago, Chile, October 2005

33. Current trends • Growing awareness that environmental change is vital • Decreasing or no private or government funding for policy work • Growth in alcohol advertising, e.g. cable TV, internet • Barrage of “health benefits” media: wine and beer for the health conscious • Increased youth access • Active industry push back • Anheuser-Busch controls 50%+ of US market – political clout at every level • Diageo enters US market and state politics; product alliances with beer • Intentionally ambiguous “drink responsibly” campaigns

34. AMA project with medical schools in college towns • Enhance role for medical school, physicians, and medical students in alcohol advocacy in AMOD communities (FSU, WI, IO, VT, GT) and others (e.g., Dartmouth, UFL) • Telecast for medical schools, directors of service learning, & medical student chapters on means to reduce college high-risk and underage drinking & related harms

35. American Medical AssociationOffice of Alcohol, Tobacco & Other Drug Abuse Preventionwww.ama-assn.org/go/alcoholwww.alcoholpolicymd.com